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Priority Public Health Conditions: Task Group 8 Summary and Proposals

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Priority Public Health Conditions: Task Group 8 Summary and Proposals Priority Public Health Conditions: Task Group 8 Summary and proposals The full report of the task group can be found at http://www.ucl.ac.uk/gheg/marmotreview/consultation/Priority_public_healt h_conditions_report Task group members: Alan Maryon-Davis (Chair), Clare Bambra, Mark Bellis, Sara Hughes, Angela Greatley, Sally Greengross, Kerry Joyce, Paul Lincoln, Tim Lobstein, Chris Naylor, Rebecca Salay, Martin Wiseman 1. Overall Aim of the Marmot Review: To propose an evidence-based strategy for reducing the health inequalities in England from 2010, including policies and interventions that address the social determinants of health inequalities. 2. Contribution of Task Group 8: Task Group 8’s work focuses on inequalities in a limited number of key ‘public health conditions’: the big causes of premature death (cardiovascular disease and cancer); obesity; and other big public health burdens such as risk- taking behaviours in younger adults (alcohol, drugs, violence), mental ill- health throughout life, and the threats to wellbeing in older people. Task Group 8 reviewed new and emerging evidence on the effects of particular policies, strategies, structures and interventions on reducing inequalities in these conditions, with a particular focus on the social determinants. On the basis of the evidence we have collated and interpreted, we have made a total of 15 proposals on what we consider to be plausible policy directions and changes in practice. We have subdivided our proposals into five key proposals, one research proposal and nine supporting proposals. Proposals in the latter category are those which overlap with the proposals of the other eight Marmot review task groups (cross-referenced where appropriate). The summary of evidence included in this Summary is by nature brief, and the full evidence review and details of the references quoted are contained in the main Report of the Task Group. 3. Inequalities in Priority Public Health Conditions 3.1. Cardiovascular Disease and Cancer Cardiovascular diseases (CVD) are the main cause of death in the United Kingdom, accounting for over 200,000 deaths every year, followed by cancers which account for over 154,000 deaths (Cancer Research UK, 2006). Within these numbers there are serious inequalities between geographical areas, gender, socioeconomic group, and ethnicity. Chronic conditions disproportionately afflict the poor and the marginalized and create further hardship and deepen poverty. Mortality and morbidity from cardiovascular disease and cancer are unevenly distributed across society with a disproportionate burden in low-income groups, minority ethnic groups and people living in the north of England. Mortality and morbidity from cardiovascular disease and cancer are also higher amongst people with poor mental health (after controlling for socioeconomic variables) suggesting an interaction between mental and physical well-being. Recent data from the British Heart Foundation indicate that there are 2.7 times more CVD deaths among men in the most deprived twentieth compared with the least deprived twentieth of the population (Scarborough et al., 2008). Similarly, socioeconomic status was shown to be related to lung cancer incidence, with people with low levels of education having a higher incidence of cancer (Menvielle et al., 2009). Likewise, modifiable risk factors for CVD and cancers such as smoking, physical inactivity, excess alcohol consumption or obesity are elevated in these population groups (Scarborough et al., 2008). As in other high-income countries, while reductions in the prevalence of some risk factors have been decreasing, inequalities have instead been widening (Clarke and Hayes, 2009). Cigarette smoking is one such example. 3.2. Obesity Obesity is causally linked to such chronic diseases as diabetes, coronary heart disease, stroke, hypertension, osteoarthritis and certain forms of cancer (Cross-Government Obesity Unit, 2008). It is predicted that as the population grows, and ages, the burden of diseases associated with obesity will result in escalating numbers of early deaths and long-term incapacity with associated reductions in quality of life (Cross-Government Obesity Unit, 2008). Childhood obesity is a particular concern and it is widely accepted that there is a link between childhood obesity and morbidity and mortality in later life (Adamson et al., 2007; Reilly et al., 2003). Obesity disproportionately affects certain population groups. As in other high income countries, obesity is associated with social and economic deprivation across all age ranges and recent research suggests that this gradient is embedded with little evidence of change over time (Adamson et al., 2007). Further, it is known that minority ethnic groups and individuals with a mental health problem or physical disability are disproportionately affected by obesity (Adamson et al., 2007; Allison et al 1999; Dinan 2004). Geographical inequalities are also evident, with hotspots in the North East, Yorkshire and Humber, and the East and West Midlands (Adamson et al., 2007). 3.3. Alcohol The relationship between socioeconomic status and alcohol is complex. For example, people with lower socioeconomic status are more likely to abstain, or, if they do consume alcohol, to have problematic drinking patterns and dependence, whereas those with higher socioeconomic status are likely to drink more often but to consume smaller amounts (Rickards, Fox & Roberts, 2004; Van Oers et al, 1999). In England across all regions, hospital admission for alcohol-specific conditions for both males and females is associated with increased levels of deprivation, with rates of admission for the most deprived quintiles being particularly high (Deacon et al, 2007). The number of alcohol- related deaths varies between English regions and also within regions. In 2005 the percentage of alcohol-specific deaths for both males and females were highest in the North West. 3.4. Drug use The links between drug use and social and economic inequalities are well recognised in literature and research: There is a significant positive correlation between the prevalence of problematic drug users aged 15-64 years and the deprivation indices of a local authority. Similarly, admission rates for drug- specific conditions for both males and females show a strong positive association with deprivation. Additionally, much of UK drug policy seeks to address factors that contribute to inequalities amongst drug users. The latest UK drug strategy, Drugs: protecting families and communities (Home Office, 2008) highlights the fact that vulnerable individuals, those who live in deprived communities and are part of disadvantaged families, are disproportionately affected by problem drug use. 3.5. Injuries and violence. The burden of injuries and violence in the UK is not equally distributed across the population, and some groups appear to be more affected than others. Incidence varies with a number of factors, which are often interlinked. These include: age, gender, socioeconomic status, ethnicity and geographical location. The relationships between these factors and injuries and violence often depend on the cause of injury (e.g. road traffic accident, fall, fire-related accident) or type of violence (e.g. self-directed violence or interpersonal violence). In general, there are higher rates of injuries and violence victimisation among individuals with a lower socioeconomic status, measured either at an area-of-residence or individual level. These associations have been reported for all age groups, and for a variety of injury types. 3.6. Mental Health In terms of disability-adjusted life-years (DALYs), mental health problems are the biggest source of health-related disability and suffering in high-income countries, accounting for 26% of the total disease burden and over 40% of ‘Years Lost due to Disability’. Unipolar depression alone accounts for 8% of the disease burden - more than any other condition (WHO 2008). In England, 23% adults met the diagnostic criteria for at least one mental health problem in the most recent national psychiatric morbidity survey (McManus et al 2009). Mental health is intimately connected with many forms of inequality. Consistent associations have been found between mental ill health and various markers of social and economic adversity – e.g. low education, low income; low socioeconomic status; unemployment; and poorer material circumstances (Melzer et al 2004). The social gradient is particularly pronounced for severe mental illness. For example, in the case of psychotic disorders the prevalence amongst the lowest quintile of household income is nine times higher than in the highest (McManus et al, 2009). However, the social gradient is also evident for common mental health problems, with a two-fold variation between the highest and lowest quintiles (McManus et al, 2009). Poor mental health also increases the incidence of and worsens the prognosis for a wide range of physical health conditions, including heart disease, stroke, cancer, diabetes and asthma. It is associated with a variety of risk factors such as smoking, drug use, alcohol abuse and obesity. It is therefore also important to consider the role of mental health and well-being when tackling inequalities across all priority public health conditions. 3.7. Health and Wellbeing of Older People According to Age Concern, approximately one in five older people live in poverty (Age Concern England, 2006). Data from the Health Survey for England 2005 show that disparities
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